Mortality vs readmit rates: "The times they are a changin' "

Dr Melissa Walton-Shirley


April 18, 2013

Come gather 'round people
Wherever you roam
And admit that the waters
Around you have grown
And accept it that soon
You'll be drenched to the bone . . .

Hmm. . . . maybe Bob Dylan was singing about the dynamics of healthcare when he wrote these iconic words, because even more "change" is certainly coming our way. With our waning financial resources, the keepers of medical treasure chests both local and national have shifted their focus away from longevity. Our new goal? Keep as many palliative-care plates spinning as possible and reduce hospital readmit rates at nearly all nonmonetary costs.

Reducing mortality . . . that's it?

Traditionally, mortality reduction has reigned as the most sought-after end point. It was the most important statistic that any study drug, device trial, innovative protocol, or advanced procedure aimed for. Now we feel the urge to apologize if we report that a treatment achieves only a reduction in mortality. Dying is cheap if it's quick and easy and certainly much cheaper than returning to the hospital with a diagnosis of CHF. More life-years could potentially break the national bank. As a result, palliative care has been birthed, kicking and screaming all over our nation into the hallways of hospitals and the homes of patients labeled as "frequent fliers" at high risk for budget-busting bounce-backs.

And there are lots of treatments already available that improve quality of life. These entities might affect the number of office visits a patient requires per year (translation: reduction in expenditures). The definition of a "positive" trial has been shifting for quite a while but is firmly shoved into the "cost" arena now.

What about Ranexa (ranolazine)? Lower mortality? Nope . . . but definite angina reduction for some, so "thumbs up."

Outpatient hemodynamic monitoring for HF? No reduction in mortality, but perhaps there will be a reduction in HF admissions, so another "thumbs up." What about nurse callbacks postdischarge? Fewer readmissions! "Thumbs up!"

EECP? No mortality reduction there, either, but there is much less angina, perhaps meaning fewer readmits, so yet another "thumbs up" for reimbursement.

LVADs? Definite lowering of mortality but costs are significant. Although most of us give this one a great big "thumbs up," "the powers that be" are arm-wrestling many of these individualized decisions into a "thumbs down."

Preventing the bounce-backs

Recently, I received a visit from a local budding "palliative-care" department. A well-meaning (and I'm certain, a competent and caring team) brought lunch and described how they would kidnap, handcuff, and duct tape . . . er, "assist" those who might be potential bounce-backs into the system postdischarge.

"Doesn't the family physician or subspecialist play the most important role here for preventing bounce-backs into the hospital?" I asked.

As she spoke, I saw a bubble slowly rise above her head, like those in the famous Sunday cartoons. Written in it were the words, "Not since Medicare reimbursement for all patient admits is tied directly to heart-failure bounce-backs, honey."

Well, just kidding. There was no "bubble," but she did say, "Actually, we will do everything possible to assist that patient so they won't need to be readmitted."

What an altruistic thought! (Although the definition of altruism is shifting as well.). But I stated that "I don't recall nearly as many bounce-backs in 30 days over the many years I was practicing in the hospital setting as there are now."

For he that gets hurt
Will be he who has stalled
There's a battle outside
And it's ragin'

When COPD, post-PCI, and post-CABG readmissions are added to the CHF readmit penalties, the cost will be in the millions for some facilities. Most of us consider readmission as a grand failure of clinical care, that we had underestimated how quickly the patient was declining or that some catastrophic thing had happened that was unavoidable or inevitable. Now a price tag will be firmly attached to every readmission, and the burgeoning failures of clinical care will induce financial disaster for individual institutions, not unlike the great stock market crash of 1929 but with an institutional twist. I can just see hospital CEOs flying out of windows all over the nation.

Staying out of the gray zones

In the greatest majority of instances, potential readmissions will be dealt with in a caring and competent manner. I know that good humans and practitioners will deliver the best healthcare possible, regardless of financial penalty, but there is a small part of me that worries that patients who need readmission will be held captive at home or in palliative-care programs or even become ensnared in a hospice-type situation when in fact there might have been help for them. No matter what practices are put in place in our country, there are those individuals and even some institutions that continuously inhabit the gray zones and margins of life where financial benefit shapes their every decision. It is those places and individuals that concern me most with the new focus in healthcare.

The consequences of aging and the act of dying of course continue on a constant basis in life, no matter who writes the check to whom for the care, but these processes will no longer be attended in the usual manner in our current healthcare system. Most of it will no longer occur in the traditional hospital setting, period. We'll do it in a healthcare facility that can't call itself "a hospital," because it can't get reimbursed with that title for helping those patients we traditionally kept in a private room with family waiting vigilantly at the bedside for the moment of passing. For patients who can survive our new system to the moment of discharge, our demeanor toward that day will change. Formerly it was celebrated instead of feared. Now, the discharge day will see a mix of party favors from the bean counters as well as a healthy dose of anxiety medications swallowed by the palliative-care team.

In this economic environment, mortality reduction is no longer the holy grail. It's a distant secondary end point. All hail lower hospital readmission rates. It's the only thing that really matters any more. Bob Dylan had it right, and to think, way back then, he didn't even know he was writing about healthcare reform:

The line it is drawn
The curse it is cast
The slow one now
Will later be fast
As the present now
Will later be past
The order is
Rapidly fadin'
And the first one now
Will later be last
For the times they are a-changin'


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